DRUG FORMULARIES

What is a drug formulary?

A drug formulary is a list of prescription medications that a drug plan will pay for.  When medications are not listed on a PDP’s formulary, then the drug plan will not pay for them unless an exception is granted.

Will there be just one drug formulary or many different ones?

Many different ones will be provided.  Each PDP providing Medicare prescription drug coverage will have its own formulary.  To determine which drug plan’s formulary meets the needs of each dual eligible, it may be necessary to examine all of the formularies.

Will any medications be available on all of the different formularies?

Yes.  CMS has designated six drug classes in which Medicare beneficiaries need uninterrupted access to all or substantially all of the drugs in that class.  However, CMS does not require that extended release products be included or that all dosages be included.   

Those medication classes are:

·        Antidepressants (e.g., Prozac, Effexor, Zoloft) used for treating depression;

·        Antipsychotics (e.g., Risperdal, Zyprexa, Seroquel) used for treating psychiatric disorders such as schizophrenia;

·        Anticonvulsants (e.g., Depakote, Tegretol, Lamictal) used for preventing or reducing seizures;

·        Antiretrovirals used or the treatment of HIV and AIDS;

·        Antineoplastics used for the treatment of cancers; and

·        Immunosuppressants used to prevent the rejection of transplants and may be used for the treatment of multiple sclerosis, lupus and some types of rheumatoid arthritis.

 What about other drug classes?

A PDP must include at least two drugs in every class. 

 Can a PDP change its formulary?

Yes, the PDP can change its formulary. However, the PDP must send a written notice of a formulary change, including a change in the cost sharing to those enrollees who use an affected drug.  The notice must be sent at least 60 days in advance of the change.

How will dual eligibles, their caregivers, and staff know whether the individual’s medications are on the formulary of their PDP?

The easiest way to compare the formularies of the different PDPs is on the Internet.  www.medicare.gov includes a method for comparing all of the PDPs near where people live.  Another family member, such as a sibling, may be able to do the Internet comparison.  Another alternative is to call the CMS toll free number, 1-800-MEDICARE (1-800-633-4227), starting in mid-October, and ask for assistance in comparing the drug plan formularies.